BACKGROUND: Hydroxyethyl starches (HES) affect the results of thromboelastography (TEG(R)). We sought to determine whether using HES rather than crystalloids for cardiopulmonary bypass (CPB) prime and ... [more ▼]

BACKGROUND: Hydroxyethyl starches (HES) affect the results of thromboelastography (TEG(R)). We sought to determine whether using HES rather than crystalloids for cardiopulmonary bypass (CPB) prime and intraoperative fluid therapy changes the TEG cutoff values best identifying patients with a low platelet count or a low fibrinogen level after CPB. METHODS: Data from 96 patients who had on-pump cardiac surgery, a TEG(R) (kaolin-heparinase) and standard investigations of blood clotting performed after separation from CPB and protamine administration were retrospectively reviewed. Patients were assigned to the HES or crystalloid group according to whether balanced 6% HES 130/0.4 or balanced crystalloids were used for intraoperative fluid therapy and pump prime. Mutlivariable linear regression models with computation of the standardized regression coefficients were used to identify independent associations between the four main TEG parameters (R time, alpha angle, K time and MA) and the type of fluid used, the INR, the aPTT, the fibrinogen level and the platelet count. Receiver-operating-characteristic curves were used to assess the effect of HES on the ability of TEG parameters to identify patients with a platelet count<80.000mul(-1) or a fibrinogen level<1.5 gr l(-1) and on the cutoff values best identifying these patients. RESULTS: The type of fluid used significantly affected the MA (P<0.001), the K time (P<0.001) and the alpha angle (P<0.001) regardless of the results of the standard clotting tests. According to standardized ss regression coefficients the platelet count and the type of fluid used were stronger predictors of the MA, the alpha angle and the K time than the fibrinogen level. MA better predicted platelets<80.000mul(-1) than K time and alpha angle (P=0.023). The best cutoff value of MA identifying patients with platelets<80.000mul(-1) was 62mm in the crystalloid group and 53mm in the HES group. MA, K time and alpha angle were poor predictors of the postoperative fibrinogen level. CONCLUSION: HES significantly changes the cutoff value of TEG(R) MA best identifying patients<80.000mul(-1) after on-pump cardiac surgery. [less ▲]

Aims Primary pre-hospital Helicopter Emergency Medical Service (HEMS) interventions may play a role in timely reperfusion therapy for patients with ST-segment elevation myocardial infarction (STEMI). We ... [more ▼]

Aims Primary pre-hospital Helicopter Emergency Medical Service (HEMS) interventions may play a role in timely reperfusion therapy for patients with ST-segment elevation myocardial infarction (STEMI). We designed a prospective study involving patients with acute myocardial infarction aimed at the evaluation of the potential benefit of such primary HEMS interventions as compared with classical EMS ground transport. Methods & results This prospective study was conducted from July 1, 2007 to June 15, 2012. Successive patients with ST-segment elevation myocardial infarction (STEMI) eligible for percutaneous coronary intervention (PCI) were included. Simulated ground-based access times were computed using a digital cartographic program, allowing the estimation of healthcare system delay from call to admission to the catheterisation laboratory. During the study period, 4485 patients benefited from HEMS activations. Of these patients, 342 (8%) suffering from STEMI were transferred for primary PCI. Median primary response time time was 11 min (IQR: 8 - 14 min) using the helicopter and 32 min (25 – 44 min) using road transport. Median transport time using HEMS was 12 min (9 – 15 min) and 50 min (36 – 56 min) by road. The median system delay using HEMS was 52 min (45 – 60 min), while this time was 110 min (95 – 126 min) by road. Finally, the system delay median gain was 60 min (47 – 72 min). Conclusions Using HEMS in a rural region allows STEMI patients to benefit from appropriate rescue care with similar delays as those seen in urban patients. [less ▲]

Preeclampsia was formerly defined as a multisystemic disorder characterized by new onset of hypertension (i.e. systolic blood pressure (SBP) >/= 140 mmHg and/or diastolic blood pressure (DBP) >/= 90 mmHg) and proteinuria (> 300 mg/24 h) arising after 20 weeks of gestation in a previously normotensive woman. Recently, the American College of Obstetricians and Gynecologists has stated that proteinuria is no longer required for the diagnosis of preeclampsia. This complication of pregnancy remains a leading cause of maternal morbidity and mortality. Clinical signs appear in the second half of pregnancy, but initial pathogenic mechanisms arise much earlier. The cytotrophoblast fails to remodel spiral arteries, leading to hypoperfusion and ischemia of the placenta. The fetal consequence is growth restriction. On the maternal side, the ischemic placenta releases factors that provoke a generalized maternal endothelial dysfunction. The endothelial dysfunction is in turn responsible for the symptoms and complications of preeclampsia. These include hypertension, proteinuria, renal impairment, thrombocytopenia, epigastric pain, liver dysfunction, hemolysis-elevated liver enzymes-low platelet count (HELLP) syndrome, visual disturbances, headache, and seizures. Despite a better understanding of preeclampsia pathophysiology and maternal hemodynamic alterations during preeclampsia, the only curative treatment remains placenta and fetus delivery. At the time of diagnosis, the initial objective is the assessment of disease severity. Severe hypertension (SBP >/= 160 mm Hg and/or DBP >/= 110 mmHg), thrombocytopenia < 100.000/muL, liver transaminases above twice the normal values, HELLP syndrome, renal failure, persistent epigastric or right upper quadrant pain, visual or neurologic symptoms, and acute pulmonary edema are all severity criteria. Medical treatment depends on the severity of preeclampsia, and relies on antihypertensive medications and magnesium sulfate. Medical treatment does not alter the course of the disease, but aims at preventing the occurrence of intracranial hemorrhages and seizures. The decision of terminating pregnancy and perform delivery is based on gestational age, maternal and fetal conditions, and severity of preeclampsia. Delivery is proposed for patients with preeclampsia without severe features after 37 weeks of gestation and in case of severe preeclampsia after 34 weeks of gestation. Between 24 and 34 weeks of gestation, conservative management of severe preeclampsia may be considered in selected patients. Antenatal corticosteroids should be administered to less than 34 gestation week preeclamptic women to promote fetal lung maturity. Termination of pregnancy should be discussed if severe preeclampsia occurs before 24 weeks of gestation. Maternal end organ dysfunction and non-reassuring tests of fetal well-being are indications for delivery at any gestational age. Neuraxial analgesia and anesthesia are, in the absence of thrombocytopenia, strongly considered as first line anesthetic techniques in preeclamptic patients. Airway edema and tracheal intubation-induced elevation in blood pressure are important issues of general anesthesia in those patients. The major adverse outcomes associated with preeclampsia are related to maternal central nervous system hemorrhage, hepatic rupture, and renal failure. Preeclampsia is also a risk factor for developing cardiovascular disease later in life, and therefore mandates long-term follow-up. [less ▲]

Perthes syndrome, or traumatic asphyxia, is a clinical syndrome associating cervicofacial cyanosis with cutaneous petechial haemorrhages and subconjonctival bleeding resulting from severe sudden compressive chest trauma. Deep inspiration and a Valsalva maneuver just prior to rapid and severe chest compression, are responsible for the development of this syndrome. Current treatment is symptomatic: urgent relief of chest compression and cardiopulmonary resuscitation if needed. Outcome may be satisfactory depending on the duration and severity of compression. Prolonged thoracic compression may sometimes lead to cerebral anoxia, irreversible neurologic damage and death. We report a fatal case of Perthes syndrome resulting from an industrial accident. [less ▲]

OBJECTIVES: Due to the recent interest in hands-only protocols for dispatcher-assisted cardiopulmonary resuscitation (CPR) and the lack of any validated algorithms in French, our primary objective was to ... [more ▼]

OBJECTIVES: Due to the recent interest in hands-only protocols for dispatcher-assisted cardiopulmonary resuscitation (CPR) and the lack of any validated algorithms in French, our primary objective was to evaluate a new French-language protocol in terms of its efficacy to help previously untrained volunteers in performing basic life support efforts of appropriate quality, and secondarily to investigate its potential utility in subjects with previous training. METHODS: Untrained volunteers were recruited among adults in a public movie centre and previously trained volunteers among undergraduate nursing students. Participants were randomly assigned to 'phone CPR' versus 'no phone CPR' by drawing sets of envelopes. Primary outcome measures were the results of the Cardiff evaluation test; the secondary measures were global scoring of a complete 5min period of CPR, in a manikin model of cardiac arrest. RESULTS: Out of 146 volunteers assessed for eligibility, 36 previously untrained candidates declined participation. 110 participants, distributed into four groups, completed the study: the previously untrained non-guided group (group A, n=30), the previously untrained guided group (group B, n=30), the previously trained non-guided group (group C, n=25) and the previously trained guided group (group D, n=25). Results of the Cardiff test and global evaluation of CPR performance revealed a significant improvement in group B as compared with group A, approaching the level of the group C. Previously trained guided bystanders had the best CPR scores, notably because of an improvement in the quality of airway management. CONCLUSION: When used by dispatchers, this new French-language algorithm offers the opportunity to help previously untrained bystanders initiate CPR. The same protocol may serve to guide volunteers with prior basic life support training to reach their best CPR performance. [less ▲]

INTRODUCTION: Functional residual capacity (FRC) measurement is now available on new ventilators as an automated procedure. We compared FRC, static thoracopulmonary compliance (Crs) and PaO2 evolution in ... [more ▼]

INTRODUCTION: Functional residual capacity (FRC) measurement is now available on new ventilators as an automated procedure. We compared FRC, static thoracopulmonary compliance (Crs) and PaO2 evolution in an experimental model of acute respiratory distress syndrome (ARDS) during a reversed, sequential ramp procedure of positive end-expiratory pressure (PEEP) changes to investigate the potential interest of combined FRC and Crs measurement in such a pathologic state. METHODS: ARDS was induced by oleic acid injection in six anesthetised pigs. FRC and Crs were measured, and arterial blood samples were taken after induction of ARDS during a sequential ramp change of PEEP from 20 cm H2O to 0 cm H2O by steps of 5 cm H2O. RESULTS: ARDS was responsible for significant decreases in FRC, Crs and PaO2 values. During ARDS, 20 cm H2O of PEEP was associated with FRC values that increased from 6.2 +/- 1.3 to 19.7 +/- 2.9 ml/kg and a significant improvement in PaO2. The maximal value of Crs was reached at a PEEP of 15 cm H2O, and the maximal value of FRC at a PEEP of 20 cm H2O. From a PEEP value of 15 to 0 cm H2O, FRC and Crs decreased progressively. CONCLUSION: Our results indicate that combined FRC and Crs measurements may help to identify the optimal level of PEEP. Indeed, by taking into account the value of both parameters during a sequential ramp change of PEEP from 20 cm H2O to 0 cm H2O by steps of 5 cm H2O, the end of overdistension may be identified by an increase in Crs and the start of derecruitment by an abrupt decrease in FRC. [less ▲]

Microsurgical free tissue transfer has become a gold standard in a wide range of clinical situations. Thrombosis at the anastomotic site is not only the most common cause of failure of microsurgical ... [more ▼]

Microsurgical free tissue transfer has become a gold standard in a wide range of clinical situations. Thrombosis at the anastomotic site is not only the most common cause of failure of microsurgical operations, but it is also one of the factors resulting in microcirculatory intravascular thrombosis in free flaps. All conditions of thrombus formation, defined by Virchow in 1856, are encountered in free flap surgery. This literature review concerns the problem of thromboprophylaxis in microsurgery. All citations published this last ten years (1996-2005) concerning this problem are noted. Data are confronted with other specialties, particularly vascular surgery, or with large retrospective studies. Protocol used in our institution is presented at the end of this lecture. [less ▲]

In this paper, the authors review the most recent literature concerning the management of the cervical spine in trauma patients. They address the main topics of concern for the anaesthesiologist including ... [more ▼]

In this paper, the authors review the most recent literature concerning the management of the cervical spine in trauma patients. They address the main topics of concern for the anaesthesiologist including pre-hospital care, clearance of the cervical spine, neuroprotective therapies, difficult tracheal intubation, and management during general anaesthesia, in the intensive care unit and in paediatric patients. The most widely accepted strategies are provided as well as alternative options. [less ▲]

Automated online tonometry displays a rapid, semicontinuous measurement of gastric-to-end tidal carbon dioxide (Pr-etCO(2)) as an index of gastrointestinal perfusion during surgery. Its use to predict ... [more ▼]

Automated online tonometry displays a rapid, semicontinuous measurement of gastric-to-end tidal carbon dioxide (Pr-etCO(2)) as an index of gastrointestinal perfusion during surgery. Its use to predict postoperative outcome has not been studied in general surgery patients. We, therefore, studied ASA physical status III-IV patients operated on for elective surgery under general anesthesia and a planned duration of >2 h in a European, multicenter study. As each center was equipped with only 1 tonometric monitor, a randomization was performed if more than one patient was eligible the same day. Patients not monitored with tonometry were assessed only for follow-up. The main outcome measure was the assessment of postoperative functional recovery delay (FRD) on day 8. Among the 290 patients studied, 34% had FRD associated with a longer hospital stay. The most common FRDs were gastrointestinal (45%), infection (39%), and respiratory (35%). In those monitored with tonometry (n = 179), maximum Pr-etCO(2) proved to be the best predictor increasing the probability of FRD from 34% for all patients to 65% at a cut-off of 21 mm Hg (2.8 kPa) (sensitivity 0.27, specificity 0.92, positive predictive value 64%, negative predictive value 70%). We conclude that intraoperative Pr-etCO(2) measurement may be a useful prognostic index of postoperative morbidity. [less ▲]

Almost twenty years ago, Trunkey showed that deaths due to trauma followed a trimodal distribution over time. Half of these deaths were delayed by at least one to two hours after the initiating insult ... [more ▼]

Almost twenty years ago, Trunkey showed that deaths due to trauma followed a trimodal distribution over time. Half of these deaths were delayed by at least one to two hours after the initiating insult. This interval (the "golden hour") can be exploited, especially in specialized trauma centers (where the most severely injured patients are cared for), to aggressively treat these patients, thereby reducing morbidity and mortality. In Belgium, this hierarchy of trauma care centers is non-existent; patients are distributed within the healthcare system randomly, depending on the localisation of the accident and the directives of the unified "100" call centre. Because this limits the number of cases any one centre treats, this type of arrangement acts to inhibit the acquisition of competency in the handling of these complex patients. The relative lack of experience of individual emergency departments leads to difficulties in establishing diagnostic and treatment priorities for the most severely injured trauma victims. The approach to these patients must follow very precise guidelines, established scientifically in order to minimize the impact of the injury on life and maximize chances of satisfactory functional recovery. In this paper, we describe the general principles of the initial approach to victims of complex multiple trauma. [less ▲]